In January, the Centers for Medicare & Medicaid Services (CMS) released a proposed ruling that will take action on transitions in care, specifically Medicare Advantage (MA) plans. After years of skilled nursing and consumer feedback, this ruling aims to divert most MA plans to home healthcare instead of skilled nursing. In addition to the transitions of these plans, the CMS ruling promises to hold accountability with Medicare Advantage and to recoup any overpayments.  

While the proposal is set to benefit providers with a clearer picture of how care will be delivered and who will be covered, it also comes with its own set of challenges. As their patients are torn between post-acute long-term care and at-home care, providers are placed in the middle between their beneficiaries and the practices that provide their care, often leading to a delay in quality care. With this new proposal, leaders in the industry are wondering who should get the final say in deciding where a patient ends up.  

In this guide, we’ll take an extensive look at the CMS’ newest proposal and how it will affect PALTC practices and healthcare providers alike.  

      Patient Placing in Medicare Advantage  

      One of the most significant consequences of the CMS’ proposal is patient placement in medical facilities and practices through their Medicare Advantage plans. Most healthcare providers are seeing a current trend among MA plans that often deny post-acute long-term care (PALTC) in favor of home care nursing and rehabilitation. These denials result in patients torn between two care forms, continually diminishing their recovery. In an excerpt from Skilled Nursing News, Crystal Bene, director of inpatient case management at Sentara Norfolk General Hospital, said that “SNF denials add to hospital length of stay and can jeopardize post-acute recovery when patients are unable to safely navigate their homes.”  

      With these SNF denials, providers are forced to go back and forth with different sectors of healthcare, often leading to a delay in care for their beneficiaries. Some professionals have even seen examples of MA beneficiaries sent to nursing homes from the hospital only for their plans to change a few days later, uprooting everything that came before. This not only harms the patient’s well-being but also places providers right in the middle of the conflict. 

      Provider Conflicts  

      In response to the CMS’ proposal, many providers expect to be caught in the middle between healthcare facilities and their patients, specifically MA beneficiaries. This has led to cause for concern over a provider’s efficiency, if they have to devote more time and effort to the placement of their MA beneficiaries, they will have to spend less time on other plans and payments. When speaking to Skilled Nursing News, Mark Traylor, president of Traylor-Porter Healthcare in Alabama, claimed the entire operation to be a “numbers game” with providers stuck right in the middle.  

      However, some providers believe the proposal will mark a significant shift in the industry, one that’s for the better. When speaking further about the proposal, Crystal Bene said, “We are working with health plans to rectify this tendency to deny, and we believe the CMS ruling will encourage patient safety and better outcomes,” Even with a glimmer of hope on the horizon, many are still debating who should get the final say of MA beneficiary’s placement.  

      Who Makes the Final Decision?  

      Lead providers in the industry are decisively split about who should determine where a patient should receive care. Some believe that the patient’s primary physician should be at the center of the decision, if not at least the start. This would not only reduce the burden for providers, but it would also focus more on the quality of care delivered to each patient. CMS made clear in its proposal that while MA plans can have a say in patient placement, it needs to be based on clinical evidence from thorough research. 

      Many industry professionals believe that providers should have the final say about patient placement with the consultation of their patients. Jonathan Gold, senior associate director of payment policy for the American Hospital Association (AHA), said, “Providers across the post-acute care continuum have reported that the prior authorization process employed by MA plans impedes their ability to provide the best care and outcomes for patients,” (Full excerpt here). This option would grant substantial control to providers, thus increasing their overall work haul.  

      One thing that is agreed upon among most providers is that physicians should be the ones to determine the criteria of decision-making in patient placement. The physicians delivering the actual care harness the proper knowledge of how to treat their patients and how their care should be provided.  

      CMS Proposal Wrapped-Up  

      Medicare Advantage providers everywhere are preparing for the ripple effects of the CMS’ newest proposal. While the proposal itself carries a handful of pros and cons, with PALTC patients being torn between various forms of care and their providers paralyzed in the middle, it’s a bid that strives to deliver the appropriate care for MA beneficiaries, no matter what that may be.  

      Curious about further updates about Medicare and Medicare Advantage, click here for our new post on Medicare Audits. 

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